April 12, 2006

Free Lunches and Conflicts of Interest

The April issue of the American Journal of Psychiatry has two interesting editorials on "Free Lunchs" and "Conflicts of Interest". Its an issue we face here at schizophrenia.com because we accept pharmaceutical company advertising money. We are, however, run by family members of people with schizophrenia and our focus will always be on what is best for them. We thought that this is an issue that all families involved in the US mental health system need to be aware of.

Free Lunch? by Kevin P. Hill, M.D.

Excerpt:

""Dr. Hill, are we changing my medicine because they gave you a pen?"

I was moments away from offering an explanation of drug half-lives when my patient's eyes brightened and she asked the question that jolted me. This 47-year-old psychopharmacology clinic patient at times seemed slow to follow the logic of our treatment plan, but this question about her anti-anxiety medication came swiftly. My cheeks and forehead were suddenly awash with warmth as I looked down and saw my pen did indeed announce the availability of a popular benzodiazepine in a new formulation. At that moment I felt bought and paid for.

My stance on the influence of drug lunches changed over the course of my psychiatry residency. At the beginning, I thought I could slide a pen into my pocket or grab a few slices of pizza without my behavior being affected. So did most of my colleagues, who eagerly engaged in small talk with drug representatives ("reps") in order to claim another mug or pocket pharmacopoeia. We wondered when the reps who brought the tasty pad thai would be back, joking that we could not recall the company for which they worked. However, some of my fellow residents refused to eat the free drug company lunch right from the start. I scoffed at them, for I thought I could save a few bucks on lunch and still choose medications for my patients in an unbiased manner.

A wealth of research has shown my initial response to the free lunches was typical for many doctors. I drew a flexible line between reasonable gifts—pens, simple lunches of sandwiches or pizza—and those gifts I thought too extravagant to accept—dinners at the most expensive restaurants in town. I was amazed at the number of brightly colored invitations to listen to an expert extol the merits of new drugs over dinner at restaurants I could not afford on my resident’s salary. While it was difficult to pass up five-star dinners, I was comfortable with my self-imposed standard for the first 3 years of my residency. I did notice, however, that each time events were held at a fancy French restaurant written up in the paper, the lectures seemed especially pertinent to me. "

Conflict of Interest - by David A. Lewis et al
The accompanying editorial from Dr. Kevin Hill, written as he finished his residency, is an articulate statement of an ever-growing conflict of interest that every physician must address in recommending treatment to a patient. His problem with a drug company pen is replicated and enhanced many fold in publishing The American Journal of Psychiatry.

Surveys of physicians find that over 90% of us look to original articles in medical journals as our most preferred source of new information for help in treating patients. That responsibility requires that journals seek 1) authors whose studies yield the most useful new information, 2) reviewers who can probe the veracity of these new findings, 3) editors who can select the best articles for readers, and 4) editorial commentators who can highlight the implications for clinical practice. The object of our conflict of interest policy is to assure our readers that each author, editor, reviewer, and commentator acts only to provide the best information for clinical practice. The task is a daunting one and, for The American Journal of Psychiatry, one that involves over 2,500 submitted articles per year (of which about 250 will be selected for publication), 20 deputy and associate editors, and over 5,000 reviewers. The editors of the Journal are entrusted with the responsibility of formulating and enforcing this policy.